Disability care

This page is designed to provide information to GP Supervisors on the key elements of disability care to teach to registrars. It highlights approaches to:
  • Assessing the range of function of patients
  • Communication
  • Preventative health
  • Navigating the NDIS
  • Detecting signs of neglect or abuse
  • History taking
  • Developmental disability checklist
  • Discussion points with patients
  • Medicare billing

How is disability defined?

A disability is an impairment or condition that impacts daily activities, communication and/ or mobility, and has lasted or is likely to last for six months or more.

FAQ – Supporting your registrar to provide best practice disability care 

Provides an overview of disability in Australia and approaches to providing holistic treatment ongoing.

Types of disability

When teaching registrars, we should first make them aware of the distinction between developmental (D- presenting in individuals between 0-18 years) and acquired disabilities (A). Types of disability include physical (D,A), intellectual (D), sensory (D,A) neurological (D,A), psychiatric (D,A), speech (D,A), physical disfigurement (D), developmental delay (D) and brain injury (A).

Assessing range of function

For registrars to work out the range of functions that may be impacted by the patients disability, it is important for them to discuss these areas: 
  1. Mobility.
  2. Ability to provide self-care i.e. ADLs.
  3. Learning style.
  4. Communication.
  5. Self-management i.e. budgeting, ability to make medical
    decisions.
  6. Social interactions.
  7. Capacity to make decisions.

Barriers

Once the range of functions that are impacted by a person’s disability are identified,  the registrar should then consider all likely barriers – physical and societal – to health care:

Financial CommunicationEquipment limitations
The doctorAttitudesLocation
Your facilityCarersKnowledge
AdministrationTimeLimitations

Communication difficulties

Your registrar needs to reflect on the challenges their patient with disabilities might face in the consultation:
Motor difficulties – ability to construct the sounds needed.
Motor planning – sequencing of speech.
Cognitive factors – intellectual or cognitive impairments.
Sensory factors – poor vision, deafness, or oral sensitivity.
Confidence – may be diminished from past experiences.
Tips Icon  
  • Find out how your practice accesses interpreters. Language interpreter services are free across Australia: the patient needs to be registered, which you should talk through with your registrar as a process. b) Sign language interpreter services are not free: the patient needs to apply to the NDIS to access (and pay through their NDIS plan for) sign language interpreters, which can be quite an expensive service and cannot be easily arranged at short notice. There is a National Relay Service that does video consults, but that’s of more relevance to Telehealth than in-practice consultations.
  • Ask the patient how they prefer to communicate. a) Carers might have strategies to help with communicating, especially with non-verbal patients. b)Remember that many deaf people are very skilled at lip reading, but don’t assume.
  • Speak as they would to anyone else of that age and gender.
  • Speak directly to the patient.
  • Use appropriate volume.
  • Observe for verbal and non-verbal cues.
  • Listen
  • Check they have been understood
    NOTE: Masks with clear plastic across the mouth are available to assist with lip reading – it is worth checking if these are on hand in your practice before seeing a patient with communication difficulties
 
  • Preventative health is very important and rarely occurs in disability care.
  • People with intellectual disabilities have high rates of preventable disease and early deaths.
 
Tips Icon

  • This issue is probably not their disability!

  • Looks can be deceiving.

  • Encourage your registrar to “check their bias”

    – Is there something stopping them from seeing the bigger picture, or an alternative diagnosis for this patient?

  • Think about access issues for investigations e.g. bloods, imaging etc.

  • Has the registrar done an appropriate examination?

    – How can they improve this in practice and/or the home setting?

The GP’s role in NDIS

The resources provided for GPs by the NDIS are readily available on the NDIS website.
•The GPSA Teaching Plan: Adults with Disabilities adds additional resources to these in a succinct, user- friendly format.

The NDIS role in patient’s disability care

NDIS responsibilitiesNDIS will not fund
Home modificationsDiagnosis and assessment
Personal care assistanceMedication, medical/ dental care, specialist services,
hospital, surgery or rehabilitation
Education to improve independenceClinical mental health care
Allied health involvementPalliative, geriatric or psychogeriatric services
Prosthetics & artificial limbsSub acute or acute treatments
Assistive technology e.g. wheel chairs, beds, hearing aidsDischarge from hospital planning
Behavioural supportsGeneral hearing or vision services
unrelated to a disability
Non- acute care in some circumstances
e.g. chronic wounds
Services needed related to a ‘medical condition’
Sex therapySex workers

Applying for the NDIS

When applying for their NDIS package and subsequent reviews / amendments, the patient needs to consider their needs in terms of three types of supports:
  • Core Supports enabling participants to complete ADLs, work towards their goals, and meet their objectives. eg: personal care assistance.
  • Capital Investments made to support participants, such as assistance technologies, equipment or home and vehicle modifications.
  • Capacity building – Supports that enable participants to build their independence and skills, for example exercise physiotherapy.
These supports are viewed by the NDIS through the lens of their relevance to the participant’s stated goals and objectives, for example:
  • To live independently.
  • To develop meaningful relationships.
  • To communicate better so they can buy their own groceries.

Tips for registrars helping new applicants with the NDIS process

  1. Ask the patient to nominate them as their “Lead Health Professional”. – The GP will still never receive any reports, but – This does ensure that involved therapists can see who the GP is which can help with communication.
  2. Always be very clear about how the patient’s condition affects their “functional ability”. – The NDIS is rejecting applications that include elements they think could be covered by a GPMP/ TCA or a hospital allied health program: it is crucial to make a clear distinction between the medical condition (not covered by NDIS) and how that medical condition is affecting the patient’s function and stopping them from achieving their objectives and living the best life possible.
  3. Tell the patient to be specific and think as broadly as possible. – I.e. “wheelchair maintenance” and “measuring & fitting” for a new powered wheelchair can be >$30,000.

Providing the required evidence for NDIS

For each functional domain, the patient provides evidence of the disability and:
  1. Impact and severity.
  2. Patient capacity to manage.
  3. The expected duration.
  4. What your patient requires to manage their disability
    i.e. suggested equipment and supports.
  5. If and how quickly your patient is deteriorating in their
    level of function.
NOTE: GPs can summarise, or attach existing medical reports, from specialists or allied health.

Writing for the NDIS

A useful tool to refer to when addressing the evidence needed to meet NDIS requirements, “GP Statement of Evidence”, can be found on the website of NDIS provider Inclusion Melbourne   NDIS providers have developed some really useful tools to aid the GP in translating their medical terminology into the language the NDIS needs at the other end.

If registrars detect and signs of abuse or neglect in their patients, below are some key contacts for referrals:

Complaints about an NDIS provider

NDIS Quality & Safeguards Commission
1800 035 544
  • The Commissioner has the power to:
    – Request further information from a person or body
    – Apply for and execute search warrants to collect evidence as part of an investigation
    – Request compulsory attendance at meetings and the production of relevant documentation
    – Conduct a public enquiry if this is in the public interest.
    Following an investigation, further action may be taken. This could be making an application to a court or tribunal. The intention is always to improve the safety of the adult and uphold their rights.

Concerns about abuse or neglect:

  • National Disability Abuse & Neglect Hotline
    1800 880 052

    “The Hotline works with callers to find appropriate ways of dealing with reports of abuse or neglect through referral, information and support. The Hotline will remain impartial – and does not take sides and does not advocate on anyone’s behalf.”
  • Immediate concerns about violence or crime
    Police – 000

Medical and social history registrars should  ask about

For new (or underassessed) patientsAlso consider
A full systems review
Areas commonly forgotten:
– Mental health or social supports– Pain management
– Bone and joint health
– Dental
– Preventative health
– Communication strategies
– Nutritional assessment: yearly weight, height, Vit D, B12/ folate
– Bowels – constipation common
– Sex and relationships
Home medication review (new and previous)
Hearing and vision assessments
Epilepsy and/or pain management plans
What outside supports or equipment are they using (or need)?
Who is the carer (if there is one)?
– Are they paid/ contracted?
– If family, are they supported too?
– Is there guardianship – who makes medical and financial decisions?

Health care checklist for an adult with developmental disability

Health concernReview frequencyPractitioner

General health

Blood pressureYearlyGP
Oral health (teeth, gums and oral cavity)Every 6 monthsDentist

Hearing

AssessmentDown syndrome – every 2 to 3 years

Non down syndrome – every 3 to 5 years
Audiologist
Correct use of hearing aidsRegularlyGP or audiologist
OtoscopyOpportunisticallyGP

Vision

AssessmentDown syndrome – every 2 to 3 years

Non down syndrome – every 3 to 5 years
Optometrist/ophthalmologist
Correct use of glassesRegularlyGP or optometrist/ophthalmologist

Points for registrars to discuss with individuals living with a disability

Bone health


  • Consider ordering a DXA scan with body composition if one has never been done.

  • Check baseline:
    – Vitamin D, Calcium, Phosphate, TSH, PTH +/- Testosterone.

  • Regular Vit D &/or calcium and nutritional assessment.

  •  Weight bearing exercise.

  • Referral for specialist management with rheumatology if high risk including minimal trauma fracture.
    – May be commenced on bisphosphonates long term.

Sexual and
reproductive health


  • Disabled people are not asexual

  • All young people need sex education

  • How your registrar can organise regular cervical smears for their patient

  • Family planning, STI screening and contraception

  • Teaching your registrar how to assess capacity to make decisions.

Pain management


  • 3:4 people with CP experience regular pain.

  • Frequently unrecognised as some people appear to show no normal signs of pain.

  • Important to manage appropriately.

Managing
behaviour problems


  • Do a proper assessment before relying on any type of “chemical restraint”

  • Drugs may be appropriate when behaviour is:
    – Persistent
    – Pervasive across different situations
    – Frequent
    – Not being caused by a correctible issue
    – Severe:
    – Causes distress
    – Causes injury to self or others
    – Compromises their health
    – Restricts their activities and community access

While a health assessment for people aged 45–49 years (inclusive) who are at risk of developing chronic disease can be billed just once, a health assessment for people with an intellectual disability can be billed and done annually*.

Case conferencing teams must include a GP and at least two other health or community care providers, one of whom can be another medical practitioner. Each team member should provide a different kind of care or service to the patient.

*It is important to complete regular health assessments for patients living with a disability each year.

Example:

Billing per year for patient with an intellectual disability:

Billing itemCost
GPMP + TCA$262.70
GPMP + TCA review$146.40
Yearly health assessment (Item 705: 45-60mins)$193.35
Home medicines review$157.30
20-40min appointment$73.95 x 10 = $739.50
Bulk billing incentive/ visit$15 x 10 = $150
1 x case conference (20-40mins)$118.60
Total per 12 months$1,767.85